GW1-2022-08395_Well Construction - GW1_20220822

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: F
1.Well Contractor Information: C
DAVID HALL 14.WATER ZONES t
Well Contractor Name FROM TO DESCRIPTION
I ,
ft. ft.
A - 4459
ft. ft. [
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 3.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3.0 n' 13.0 ft' 2.0 n 1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 1.0 ft' PORTLAND BENTONDE SLURRY
MMonitoring ❑Recovery ft. fr.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMEFHOD
❑Aquifer Test ❑Stortmwater Drainage 2.0 r'• 13.0 r`' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soivrock type,grain size,etc.
0.0 r� 5.0 rt' SAND/GRAVEL
4.Date Well(s)Completed: 08/09/22 Well ID# MW-3 5.0 r� 13.0
5a.Well Location:
ARNOLDS GROCERY r` r` AIJF3 2. W 2022
Facility/Owner Name Facility ID#(if applicable) ft. ft.
t ..a•
610
407 US 15-501 CARTHAGE 28327 ft. rr. ;)l'll�✓ "'7
Physical Address,City,and Zip
ft. ft.
MOORE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-2.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification: /,
350 22' 39.14" N 790 17' 20.16" W � / �
08/16/22
6.Is(are)the well(s): EPermanent or ❑Temporary Signature ofCenified Well Contractor Date
By signing this farm,I hereby cert fy that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or hA NCAC 02C.0200 Well Construction Stondords and that a copy
lfihis is a repair,Jill out known well construction inJornnatton and explain the nature oJ7he ofthis record has been provided to the well owner.
repair under#2I remarks section or on the back afMa Jorm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 13.0 (ft.)
For multiple we/ts list a//depths ifdifferent(example-3 a 00'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 9.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
!J'water level is above casing,use"+ Information Processing Unit,1617I MSC,Raleigh,NC 27699-1617
"
$•Q 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.)
Program, 1636 MSC,Raleigh,NCi27699-1636
12.Well construction method: AUGER f
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program, 1611 MSC,Ralei I gh',NC 27699-161 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018